Dozens of Victorians die in blunders as hospitals feel the squeeze

Dozens of Victorians were killed or seriously harmed by catastrophic errors or negligence in hospitals over the past two years and in some cases a shortage of resources may have played a role.

The Victorian government's latest report on adverse or ''sentinel'' events revealed 75 people over the past two years were victims of potentially deadly mistakes.

These included people committing suicide in hospitals where they should have been monitored, gross medication errors, people having surgical instruments left inside them, inadequate monitoring of patients' conditions and infection control breaches.

While the total number of sentinel events has consistently declined for the past three years from 58 in 2010-11 to 41 the next year and 34 last year, the report revealed a spike of four medication errors potentially causing patients' deaths in 2011-12.

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A Victorian government report revealed 75 people over the past two years were victims of potentially deadly mistakes.Credit:AFR

Last year, 27 people died as a result of an adverse event, down from 33 the year before, and two people were harmed with temporary injuries in 2012-13 compared with four the year before. Only six patients of 75 over the two years were not harmed by the adverse event.

The report said one ''maternal death or serious morbidity associated with labour or delivery'' occurred during the two-year period.

In one example of the danger of running hospitals at full capacity, a person diagnosed with kidney failure and with a history of heart disease died after there was no intensive care unit bed available and their condition was inadequately monitored and communicated between staff.

The report said the patient was managed in the emergency department under the care of the intensive care unit team, but was then admitted to a general ward without staff having an understanding of their deteriorating condition.

''Shortly after the patient's transfer to the ward, the patient was found unconscious. Resuscitation attempts were unsuccessful and the patient died,'' the report said. The hospital, which was not named, has since developed a plan for managing seriously ill patients when no intensive care beds are available.

Other cases outlined in the report include:

■ An elderly patient choked to death after being fed a sandwich for dinner despite an alert on their medical record saying they were at risk of choking and needed soft foods only.

■ A patient died soon after falling out of bed. The patient was alone at the time of the fall.

■ A patient suffered an infection in the bowel after a wound pack was left inside them during colorectal surgery to remove a tumour.

■ A patient died soon after being wrongly given crushed medication through an intravenous line.

■ A patient was exposed to the risk of infection during surgery after having dirty forceps used on them.

■ A patient was left with a permanent reduction in function after having a cannula inserted into the wrong part of the body during a radiological procedure.

In Victoria, a ''sentinel'' or ''adverse event'' is defined as a ''rare event leading to serious patient harm or death, which is specifically caused by healthcare rather than a patient's underlying condition or illness''.

In 2012-13, there were about 1.5 million admissions to Victorian hospitals and 153,000 planned surgical procedures.